Transcript Stitches in Time - Michael Rachlis

Public Sector solutions to
Health Care Queues
Michael M. Rachlis MD MSc FRCPC
(www.michaelrachlis.com)
New Brunswick Ministry of Health and Social
Services May 5, 2009
Outline
• Canada, like many countries has long waits for care
• In Canada, up until recently, there has been little
application of formal queue management methods
for healthcare queues
• Queuing problems are just one aspect of poor
quality
• How to reduce health care wait lists
• For profit patient care tends to be more expensive
and of poorer quality
• Re-engineering for quality
K Davis.
Commonwealth
Fund April 2006
% Long Waiting Times
Germany,
CAN, US
(CAN, USA, Germany)
Elective surgery
wait > 4 months
Specialist wait
times > 4 weeks
ER wait > 2 hr
> 5 d for GP
appointment
0%
10%
20%
30%
40%
50%
60%
Queuing problems are
just one aspect of
poor quality care
Canada Has Big Quality Problems – Most
are similar to those of other countries
• Misuse
– Canadian Adverse Events Study
• 9000 to 24,000 preventable hosp deaths/yr
• (GR Baker et al. CMAJ 2004;170:1678-1686)
• 5-10 % of all deaths in developed countries are
deaths in hospital caused by the health care system
• Overuse
– Medication and the elderly
• Under use
– Chronic disease management and prevention
Do one-fifth of older Canadian women
need to take Benzodiazepines?
Do we care what we’re paying for?
Six values for Quality Improvement
(US IOM Crossing the Quality Chasm
2001. www.iom.edu)
1.
2.
3.
4.
5.
6.
Safety
Effectiveness
Patient-centredness
Timeliness
Efficiency
Equity
Attributes of High Performing Health
Systems Ontario Health Quality Council.
April 2006. (www.ohqc.ca)
1.
2.
3.
4.
5.
6.
7.
8.
9.
Safe
Effective
Patient-Centred
Accessible
Efficient
Equitable
Integrated
Appropriately resourced
Focused on Population Health
How to reduce health care
wait lists
What causes queues?
• Usually there is enough
overall capacity
• Queues usually develop
because of temporary
capacity demand mismatches
Temporary capacity/demand mismatch in a
system with only 10% variation twice a week
• Monday, Wednesday, Friday: 10 patient
demand, 10 units of capacity, no waiting list
• Tuesday: 9 patient demand, 11 units of
capacity, no waiting list, 2 wasted units of
capacity – lost forever
• Thursday: 11 patient demand, 9 units of
capacity, 2 patients put on the waiting list
• After one year 104 people are waiting and
there’s moral panic. BUT average capacity
equals average demand
Endoscopy Queues in Birmingham
Why is there still a backlog
after 2 wait list initiatives?
What’s going
on here?
Capacity and demand for Endoscopy in
Birmingham – Average Capacity is almost always
greater than average demand!
Theatre time
(minutes)
Capacity (Max)
Actual capacity
endoscopists
Activity
4500
4000
3500
3000
2500
Demand
Cidex leak
2000
1500
1000
500
0
25/03
18/03
11/03
04/03
25/02
18/02
11/02
04/02
28/01
21/01
14/01
07/01
31/12
24/12
17/12
10/12
03/12
26/11
19/11
12/11
05/11
29/10
22/10
15/10
08/10
01/10
/2002
/2002
/2002
/2002
/2002
/2002
/2002
/2002
/2002
/2002
/2002
/2002
/2001
/2001
/2001
/2001
/2001
/2001
/2001
/2001
/2001
/2001
/2001
/2001
/2001
/2001
Matching variation in demand and
capacity (Dr. Martin Lee’s breast clinic)
2 clinics per week with 54 appt
Slots. This should have been enough
Capacity. But temporary mismatches
Meant Dr. Lee struggled to see all
patients in the 2 wk standard
Number
The Solution? Reduce
capacity 10% to 48 appts
But spread them out over 3
clinics. Now All patients
Are seen in 5 days
60
50
40
30
20
10
0
Total number of
Patients referred
Number of clinic
slots available
Week
Variation in clinical systems
Process
Staff
motivation
skills
holiday
illness
shifts
GP
training
machines
supplies
Rooms
All Different
unclear
Patients
age
motivation
disease
guidelines
race education
differ
sex
complications
anaesthetics
transcription
Discharged!
transport
applications
Resources Information
We control 80%
of variation!
15
Variation kills quality
Risk for bad outcome after discharge from hospital and % of
all discharges, by day of hospital discharge (Ontario data)
Why are
there 2 ½
times more
discharges
on Friday
than
Sunday?
And, why
are Friday
discharges
15% more
likely to
suffer a bad
outcome?
van Walraven, C. et al. CMAJ 2002;166:1672-1673
Six Steps to reduced waiting
1.
2.
3.
4.
Map the process
Eyeball the map
Eliminate redundant stages
At each stage measure demand and
Capacity
5. If Capacity is greater than demand…
6. If Capacity less than demand…
1. Map the process
• Follow the patients through the process
using their eyes
• Don’t miss the informal stages
• Measure time at each stage
2. Eyeball the map
•
•
•
•
Use a patient-centred view
Are there redundant stages?
This is the time for creativity
It’s a complex system
– Small changes may have big consequences
AND vice versa
“I have a good doctor and we’re good friends. And
we both laugh when we look at the system. He sends
me off to see somebody to get some tests at the
other end of town. I go over there and then come
back, and they send the reports to him and he looks
at them and sends me off some place else for some
tests and they come back. Then he says that I had
better see a specialist. And before I’m finished I’ve
spent within a month, six days going to six different
people and another six days going to have six
different kinds of tests, all of which I could have had
in a single clinic.”
Tommy Douglas
3. Eliminate redundant stages
• Capital Health Edmonton decreased
delays for diabetic education by > 90% by
not insisting patients see a diabetologist
on the first visit to the centre
• Sault Ste. Marie decreased delays from
mammogram to definitive diagnosis by
75% collapsing visits for mammogram,
ultrasound, and biopsy
4. At each stage measure
demand and capacity
• Demand should be measured
prospectively with regard for
appropriateness
• Capacity should be identified with
regard to the actual length of time to
provide services
• Measure variation
We want to meet the demand for
appropriate care. Too much healthcare
is inappropriate
• Wright et al CMAJ 2002
– 25% of cataract operations were
questionable
• CAT and MRI scan overuse?
5. If Capacity is greater than demand…
• Work down backlog
• Identify temporary capacity/demand
mismatches
• Reduce variation to eliminate or
decrease capacity/demand mismatches
– Re-shape demand
– Smooth capacity
Reducing and reshaping demand
Re-shaping demand
• Can you do anything to prevent illness
and reduce demand for your service
• Can you deal with your service demand in
a more efficient fashion?
– What are the alternative courses
– What are their advantages and
disadvantages
• What are the barriers to reshaping
demand for your service
Smoothing capacity
• Do you have the data?
• Can you match your capacity to your
demand?
• What are the barriers to flexibly using
your capacity?
6. If Capacity is less than demand…
• Identify temporary capacity/demand
mismatches
• Reduce variation to eliminate or decrease
capacity/demand mismatches
– Shape demand
– Smooth capacity
6A. If your Capacity is now greater
than demand…
• Go to Step 5
6B. If your Capacity is still less than
demand…
• Which resources are the constraint
– Capital
– Human
– Other operating resources
• Add appropriate new resources
• Find the new bottleneck
– There will always be one part of the
process which runs slower than others
• Continue to “chase the bottleneck”
Good News!
We could solve
almost all our
problems
with innovation
and quality!
Good News! We could access
primary health care within 24 hrs
“Even if we did nothing else,
and we should implement
other reforms, if every family
physician implemented
Advanced Access, every
Canadian could have a family
doctor.”
Penticton British Columbia’s Dr. Jeff
Harries to the CMA meeting, “ Taming the
Queue”. Ottawa. March 31, 2006
Good News! We could have elective
specialty consultations within one week
– The Hamilton Family Medicine Mental
Health Program increased access for
mental health patients by 1100%
while decreasing psychiatry
outpatients’ clinic referrals by 70%.
– The program staff includes 150 family
doctors, 80 mental health counsellors,
and 17 psychiatrists and provides care
to 300,000 patients
Good News! We could have
elective surgery within two months
– In Toronto, Barrie, and
other parts of Ontario
arthritis patients are
assessed within two
weeks for joint
replacements and have
their surgery within
two months
And, limited understanding of queueing
“They (wait lists) are the inevitable result of a public
system that can consequently offer universal access
to health services within the limits of sustainable
public spending.”
“The expert witnesses at trial agreed that waiting
lists are inevitable. The only alternative is to have a
substantially overbuilt health care system with idle
capacity.”
Canadian Supreme Court Minority
Chaoulli 2005
For profit patient care
tends to be more expensive
and of poorer quality
For profit delivery: In general -higher costs, worse outcomes
• PJ Devereaux et al (CMAJ. 2002;166:
1399–1406. CMAJ 2004;170:1817–1824)
– For profit hospitals had 2% higher death
rates and 20% higher costs
For profit delivery: In general -higher costs, worse outcomes
• PJ Devereaux et al (JAMA. 2002;288: 2449–
2457.)
– For profit dialysis clinics had 8% more deaths
– For-profit clinics had fewer and less trained staff
– For profit clinics dialyzed patients for less time
and used lower doses of erythropoietin
– In the US, 2,000 premature deaths occur every
year among dialysis patients using for-profit
clinics.
Contracting out clinical services isn’t
nearly as easy as the advocates claim
(Deber 2002)
•
•
•
•
•
low contestability
high complexity
low measurability
susceptibility to cream skimming
externalities
“Before the buy-out, I could have
taken the money and gone on
vacation. Now the surpluses are used
to treat more patients.”
Dr. Wayne Hildahl, Executive Director,
Winnipeg Regional Authority Pan Am
Clinic (and former private owner)
Externalities -- Non Profits are
more likely to:
• Expend resources on linking different
organizations together to plan
community networks
• Engage their communities and enlist
volunteers
• Provide benefits, continuing education,
and training to their staff
Some public private partnerships do work!
To quote Tony Soprano,
“Fuhgetaboutit!”
There are public sector solutions
to all of Medicare’s problems.
See M Rachlis “Private Health
Care won’t Deliver”
(http://www.michaelrachlis.com
/pubs/2007%20Rachlis%20privat
e%20public.pdf)
Re-engineering for quality
• Saskatchewan Health Quality Council
(www.hqc.sk.ca)
• Ontario wait list management
(http://www.health.gov.on.ca/transformation/wait_times/wait_mn.html)
• Ontario Health Quality Council (www.ohqc.ca)
• Winnipeg’s Pan Am Clinic
(http://www.panamclinic.org/)
• Toronto’s Trillium Health Centre Surgicentre
(http://www.trilliumhealthcentre.org/programs_services/surg
ical_services/queensway/surgicentre.html)
Re-engineering for quality
• Why Wait? Public Solutions to Cure Surgical Wait
lists
(http://www.michaelrachlis.com/pubs/070508%20BC%20wait
lists%20paper%20final.pdf )
• Public Solutions to Health Care Wait Lists
(http://www.policyalternatives.ca/documents/National_Office_Pubs/2005
/Health_Care_Waitlists.pdf)
• Institute for Healthcare Improvement (www.ihi.org)
• Improving Patient Flow (http://www.steyn.org.uk/)
Summary:
• Canada, like many countries has long waits for care
• In Canada, up until recently, there has been little
application of formal queue management methods
for healthcare queues
• Queuing problems are just one aspect of poor quality
• There are public sector strategies to eliminate waits
and delays and deal with other quality problems
• For profit care tends to cost more and deliver less
• Let’s re-engineer for quality
“Courage my
Friends, ‘Tis Not
Too Late to Make
a Better World!”
Tommy Douglas
(per Alfred Lord
Tennyson)